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					Evaluating ED Patients Who
Present with AMS & Coma:
  A Systematic Approach

             Edward P. Sloan, MD, MPH, FACEP
   Edward Sloan, MD, MPH
               Professor

  Department of Emergency Medicine
University of Illinois College of Medicine
                Chicago, IL
                    Edward P. Sloan, MD, MPH, FACEP
      Attending Physician
      Emergency Medicine

    University of Illinois Hospital
Our Lady of the Resurrection Hospital

            Chicago, IL
                  Edward P. Sloan, MD, MPH, FACEP
           Global Objectives
•   Improve coma pt outcome
•   Know how to quickly evaluate coma risk
•   Determine how to use empiric meds
•   Provide rationale for ED neuroimaging
•   Facilitate disposition, improve pt outcome
•   Improve Emergency Medicine practice

                        Edward P. Sloan, MD, MPH, FACEP
          Session Objectives
•   Present a relevant patient case
•   Discuss key clinical questions
•   State key learning points
•   Review the coma evaluation procedure
•   Discuss the procedure of empiric meds
•   Evaluate the patient outcome and
      ED documentation
                       Edward P. Sloan, MD, MPH, FACEP
A Clinical Case



       Edward P. Sloan, MD, MPH, FACEP
     EMS Presentation
• 54 year old EMS call for “found down”
• Pt in street
• Possible seizure
• Unresponsive
• Glucose normal
• No other history available


                    Edward P. Sloan, MD, MPH, FACEP
       ED Presentation

• Pt unresponsive
• Vitals: BP 220/110 HR 110 RR 16
• Afebrile
• No trauma
• Normal cardiopulmonary, abdomen
• Minimal twitching of R face noted

                   Edward P. Sloan, MD, MPH, FACEP
      Key Clinical Questions
•   How to evaluate this unresponsive pt?
•   What is the differential diagnoses?
•   What are the etiologies of coma?
•   What tests must be performed?
•   What neuroimaging to be obtained?
•   What therapies must be provided?


                       Edward P. Sloan, MD, MPH, FACEP
AMS & Coma:
Key Concepts



      Edward P. Sloan, MD, MPH, FACEP
     Stupor & Lethargy

• Stupor definition:
  –A state of reduced or suspended
  sensibility, a daze
  –Decreased responsiveness
  –Similar to lethargy
• Reduced GCS, but above 8
                  Edward P. Sloan, MD, MPH, FACEP
         Acute Delirium
• Delirium definition:
  –Mental confusion
  –Clouded consciousness
  –Disorientation, hallucinations
  –Delusions, anxiety
  –Incoherent speech
• GCS generally above 8
                    Edward P. Sloan, MD, MPH, FACEP
                Coma
• Coma definition:
  –Extreme alteration in mental status
  –Unresponsive
  –Similar to being unconscious
• Markedly low GCS, 8 or less



                     Edward P. Sloan, MD, MPH, FACEP
  Coma Pathophysiology
• Bilateral cerebral cortex dysfunction
  – Toxic/metabolic
  – Mass lesion, increased ICP
  – Cerebral ischemia, infarct
• Brainstem suppression of reticular
  activating system (RAS)
  – Ischemia, infarct

                        Edward P. Sloan, MD, MPH, FACEP
      Coma Etiologies
• Hypoperfusion/ischemia
• Toxic/metabolic
• Increased ICP
  –Chronic space-occupying lesion
  –Acute hemorrhage
• Infection
• Seizure
• Psychogenic fugue state
                   Edward P. Sloan, MD, MPH, FACEP
          Coma Etiologies
•   T   trauma, temperature
•   I   infections
•   P   psychiatric, porphyria
•   S   space-occupying lesion,
         stroke, SAH



                      Edward P. Sloan, MD, MPH, FACEP
          Coma Etiologies
•   A   alcohol, other toxins
•   E   endocrine
•   I   insulin (DM complications)
•   O   oxygen deficiency, opiates
•   U   uremia, renal disorders



                      Edward P. Sloan, MD, MPH, FACEP
Coma Pt Treatment Priorities
• Assess ABCs, vitals
• Provide empiric therapies
• Assess for signs of likely etiology
  –Trauma, toxic, infection, ischemia, tumor
• Conduct a systematic neurological exam
• Obtain neuroimaging
• Consider EEG monitoring
                       Edward P. Sloan, MD, MPH, FACEP
A Perspective on Procedures
• Critically ill ED patients
• Coma is a true medical emergency
• Limited time and resources
• A need to diagnose and act
• “Emergency physicians take a surgeon’s
  approach to medical emergencies.”
• We do procedures
                    Edward P. Sloan, MD, MPH, FACEP
Empiric Therapies:
 The Procedure

        Edward P. Sloan, MD, MPH, FACEP
Empiric Therapies: Principles
• Airway management:
    – Nasal or oral airway, ventilate, prepare for RSI
•   Oxygen therapy
•   Obtain an accucheck, administer glucose
•   Fluid bolus for hypotension
•   Naloxone if evidence of narcotic use/abuse
•   Judicious flumazenil use for benzo abuse
•   Thiamine in alcohol abuse
                           Edward P. Sloan, MD, MPH, FACEP
         Empiric Therapy
• Control the airway, ventilate




                      Edward P. Sloan, MD, MPH, FACEP
         Empiric Therapy
• Control the airway, ventilate
• Do a bedside glucose determination
  – Provide D50 for hypoglycemia
  – Avoid hyperglycemia




                      Edward P. Sloan, MD, MPH, FACEP
         Empiric Therapy
• Control the airway, ventilate
• Do a bedside glucose determination
  – Provide D50 for hypoglycemia
  – Avoid hyperglycemia
• Detect hypoperfusion (Decreased CPP)
  – CPP = MAP – ICP (MAP > 90 mmHg key)
  – NS fluid boluses up to 500 cc each
                      Edward P. Sloan, MD, MPH, FACEP
          Empiric Therapy
• Assess for narcotic overdose
  – Nalaxone 2 mg IV or sublingual
  – Be prepared to restrain patient




                        Edward P. Sloan, MD, MPH, FACEP
          Empiric Therapy
• Assess for narcotic overdose
  – Nalaxone 2 mg IV or sublingual
  – Be prepared to restrain patient
• Assess for benzodiazepine overdose
  – Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)
  – If acute ingestion, initial dose OK, no seizure


                         Edward P. Sloan, MD, MPH, FACEP
          Empiric Therapy
• Assess for narcotic overdose
  – Nalaxone 2 mg IV or sublingual
  – Be prepared to restrain patient
• Assess for benzodiazepine overdose
  – Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)
  – If acute ingestion, initial dose OK, no seizure
• Examine for likely EtOH abuse
  – Thiamine 100 mg IVP or to IVF
                         Edward P. Sloan, MD, MPH, FACEP
Coma Patient Evaluation:
    The Procedure

           Edward P. Sloan, MD, MPH, FACEP
      Coma Exam: Principles
•   Many etiologies are apparent on exam
•   Step-wise approach allows for detection
•   Follows empiric therapies
•   Precedes, directs neuroimaging
•   Establishes baseline
•   Mental status change then detectable

                        Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Assess the pt’s overall mental status




                      Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Assess the pt’s overall mental status
• Assess the ABCs (trauma)
  – Airway & gag reflex
  – Breathing pattern and sufficiency
  – Circulation adequacy and hypotension



                      Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Assess the pt’s overall mental status
• Assess the ABCs (trauma)
  – Airway & gag reflex
  – Breathing pattern and sufficiency
  – Circulation adequacy and hypotension
• Assess the skin, breath (toxidromes)

                      Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Assess the pt’s overall mental status
• Assess the ABCs
  – Airway & gag reflex
  – Breathing pattern and sufficiency
  – Circulation adequacy and hypotension
• Assess the skin, breath (toxidromes)
• Detect posturing following stimulation
                      Edward P. Sloan, MD, MPH, FACEP
Decorticate posturing in comatose patient
Lesion above the red nucleus

Lower limbs extend, upper limbs flex following stimulus

Activity in the brainstem flexor center, the red nucleus




                               Edward P. Sloan, MD, MPH, FACEP
       Decerebrate posturing in comatose patient

Upper and lower limbs extend following stimulus
      (pain, startle,or auditory)
Normal inhibition by cortex on the extensor facilitation part of
      ret form is missing, so extensors hyperactive
Lat vest nuclei involved, ablate and extensor posturing reduced




                                 Edward P. Sloan, MD, MPH, FACEP
 Clinical Value of Decorticate/Decerebrate Signs
Decorticate posturing indicates a higher level of brainstem
      injury than decerebrate posturing (a good thing), so

Comatose patients who go from decerebrate to decorticate
     (ascending progression of impaired area) have
     a better prognosis than those that go from decorticate to
     decerebrate (descending progression of impaired area).

Descending impairment will be fatal if medullary respiratory
     and cardiovascular centers are damaged



                                Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Calculate the Glasgow Coma Scale score
 – Eye Opening (4), Verbal (5), Motor (6)
 – 13-15 Mild AMS, 4-8 Coma, 3 Vegetative




                      Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Calculate the Glasgow Coma Scale score
  – Eye Opening (4), Verbal (5), Motor (6)
  – 13-15 Mild AMS, 4-8 Coma, 3 Vegetative
• Detect abnormal reflexes
  – Corneal reflex
  – Babinski (Chadduck)


                       Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Examine the pupils
  – Size and equality
  – Light reactivity, consensual response




                        Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Examine the pupils
  – Size and equality
  – Light reactivity, consensual response
• Perform the Doll’s eye maneuver




                        Edward P. Sloan, MD, MPH, FACEP
        Doll’s Eye Maneuver
•   Oculocephalic reflex
•   Caution with suspected c-spine injury
•   Eyes should continue to face to ceiling
•   If eyes follow movement of head to side,
    suspect brainstem involvement in coma



                        Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Examine the pupils
  – Equality
  – Light reactivity
• Perform the Doll’s eye maneuver
• Detect evidence of psychogenic coma
  – Protective reflex
  – Propriety reflex
                        Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Look for ongoing seizure activity




                      Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Look for ongoing seizure activity
• Perform cold calorics




                      Edward P. Sloan, MD, MPH, FACEP
  Cold Caloric Examination
• Oculovestibular reflex
• Normal for slow movement of eyes
  towards, fast movement away from cold
  water into ear canal
• If eyes move towards cold water, intact
  brainstem despite coma
• If no eye movement towards stimulation,
  suspect brainstem injury
                     Edward P. Sloan, MD, MPH, FACEP
Coma Evaluation Procedure
• Look for ongoing seizure activity
• Perform cold calorics
• Document checklist of coma findings
  – Presence of coma, responsiveness, GCS
  – Vital signs, ABCs, empiric therapies
  – Exam findings checklist
  – Likely etiology
  – Likely location of lesion
                      Edward P. Sloan, MD, MPH, FACEP
ED Documentation &
 Patient Outcome



         Edward P. Sloan, MD, MPH, FACEP
 ED Coma Documentation
• Pt unresponsive to all stimuli cw coma
• Airway adequately controlled
  – Decreased gag reflex
  – OK Airway with nasopharyngeal airway
• Adequate ventilation, pO2 OK 100% NRB
• Hypertension noted, tachycardia
  – Labetalol 20 mg IVP
  – Repeat BP OK
                          Edward P. Sloan, MD, MPH, FACEP
 ED Coma Documentation
• No pallor, cyanosis, or cherry red skin
• No abnormal breath or EtOH
• Adequate ventilation, pO2 OK 100% NRB
• Hypertension noted, tachycardia
  – Labetalol 20 mg IVP
  – Repeat BP OK
• No pathologic posturing to stimulation
• Estimated GCS = 3
                          Edward P. Sloan, MD, MPH, FACEP
 ED Coma Documentation
• Corneal reflex intact, no upgoing toes bilat
• Pupils midrange, equal, reactive
• Fixed gaze to R, no Doll’s eyes noted
• Protective reflex to arm dropping absent
• No propriety reflex noted
• Facial twitching noted on R, likely SE
• Cold calorics not indicated
                      Edward P. Sloan, MD, MPH, FACEP
 ED Coma Documentation
• Coma
• Likely etiology subtle status epilepticus
• No toxidrome or intoxication
• Non-focal exam, mass lesion not likely
• No evidence psychogenic seizure
• CT negative, tox screen negative
• Lorazepam, fosphenytoin
• EEG negative in ED
                      Edward P. Sloan, MD, MPH, FACEP
      Patient Outcome
• Hx SE, compliant with meds?
• Hx carotid occlusion
• Due to have carotid endarterectomy
• Pt remained unresponsive after EEG
• Admitted for ongoing observation
• Expedited surgery anticipated

                   Edward P. Sloan, MD, MPH, FACEP
ED Comatose Patient Exam:
     A Retrospective


            Edward P. Sloan, MD, MPH, FACEP
    ED Comatose Patient Exam
•   Address the ABCs
•   Quickly assess for coma etiologies
•   Perform a systematic neuro exam
•   Expedited neuroimaging, consultation
•   Documentation of coma checklist
•   Definitive care plan established in ED
•   Optimized coma patient outcome
                      Edward P. Sloan, MD, MPH, FACEP
                                           Questions??

                                            www.ferne.org
                                           ferne@ferne.org

                              Edward Sloan, MD, MPH
                                edsloan@uic.edu
                                  312 413 7490
ferne_2005_ieme_sloan_BIC_coma_fshow.ppt
1/24/2013 10:47 PM                                Edward P. Sloan, MD, MPH, FACEP

				
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